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Minor Surgery of the Foot
MINOR SURGERY OF THE FOOT JAMES K. STACK, M.D., F.A.C.S. o AFFECTIONS OF THE NAILS
Ingrown Toenail.-In childhood and the teen age the most common affection of the toenails is of the medial aspect of the great toe. This affection is almost invariably due to the pressure of a malfitting shoe or short sock. The Heshy part of the medial surface is compressed so that the medial comer of the nail in its growth will perforate the epithelium and set up a low grade infection. The onset is usually followed by the appearance of a granuloma which will pile up over the edge of the nail and be fostered by the destroyed portion of the nail which acts as a foreign body or sequestrum. No direct surgical interference should be considered in the presence of active infection. It will be found that the application of warm, moist boric acid dressings and the forswearing of a shoe or sock will result in a rather rapid regression of the granuloma and the disappearance of the signs ofinHammation in the involved tissues. It is at this stage that minor surgical procedures will be effective. We hesitate to make a radical excision of the medial border of the nail and its matrix in a child, because there is no need to narrow the nail permanently, and frequently the matrix will not be completely destroyed and little spurs of nail will grow through the scar in its proximal portion. A simple excision of the comer or border of the nail or, if necessary, the removal of the entire nail without destruction of the matrix, will suffice. This can then be followed by training of the new nail as it grows out, and instruction to the parents as to the proper type of wide toe shoe and the need for adequate length in the stocking. This type of nail affiiction was seen with great frequency in the armed services and was, of course, due to the aforementioned factors, plus careless or improper foot hygiene. In the adult it is quite a different story. The nail is no longer Hat but tends to form an inverted "U," so that ingrowth and perforation of the skin covering will not only occur at the comer but may occur along the entire medial and/or lateral side. The management of the active infection is no different than in the child, but for best results the nail should later be permanently narrowed. This can be readily done under local anesthesia, obtained either by direct infiltration of the end and side of the toe or by a block of the digital nerves at the o Assistant Professor of Bone and Joint Surgery, Northwestern University Medical School; Attending Surgeon, Cook County Hospital; Attending Surgeon, Passavant Memorial Hospital, Chicago. 196
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base of the toe. A rubber band tourniquet or a twisted gauze dressing with a hemostat will give a suitable bloodless field, so that the edges of the nail bed and matrix c~n be visualized and completely removed. Following the healing phase, the patient should be cautioned to train the comers of the new nail to grow Hat, and when trimming the nail to cut only straight across. Small wisps of cotton tucked under the nail comer with a toothpick, knife blade or hairpin will keep it elevated during the training period. Dorsal Hypertrophy; Horn Formation.-Another common afHiction of the nail in adult life, particularly in the more advanced decades, is hypertrophy and piling up of the dorsum of the nail. It then has a tendency to make inroads on the Hesh of both sides, so that in looking at it from the end of the toe it forms an inverted "u" or may even be horseshoe-shaped with a circular mass of skin within it. Many such nails are the result of a true fungus involvement, but many more are simply growth abnormalities, the basis of which has not been firmly established. These patients will complain of the actual bulk of the nail pressing against the top of the shoe, and this pres~ure will in tum be referred down along the circular edges, giving pain on each side. They can be helped a good deal by shaving or filing the top of the nail Hat, so that regrowth is ,concentrated on the dorsal surface rather than on the surfaces making up the arms of the horseshoe. Also, the Hat surface will be subjected to less pressure and subsequently cause less pain. In extreme instances of actual hom formation the nails must be cut with a rongeur or bone-biting forceps, or they will have tq be removed with the hope that the new nail will have less tendency to overgrowth. In these cases chitinous debris will usually be found beneath the distal portion of the nail and this should be removed with an orange stick or cotton as part of the daily care. The application of cold cream to the cuticle and the surrounding skin will keep these structures soft and enable them to better withstand the pressure exerted on them throughout the day by the nail itself. These same lesions may occur in the nails of other toes, but seldom with the same frequency or with the same degree of irritation. There is no esesential difference, however, between the treatment of nail abnormalities of the great toe alld any other toe that might be involved. Subungual Lesions.-The subungual space is frequently the site of painful and potentially serious lesions. The commonest is the subungual hematoma which is a collection of blood due to rupture of the vessels of the nail bed. The blood then creates considerable tension within the closed space and produces a severe throbbing pain. This lesion is the result, as might be expected, of falling objects striking the nail. Relief is immediate when the hematoma is evacuated by drill hole or slit in the softer proximal portion of the nail over the
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Iunula. Simple sterile precautions will suffice as after-care, but loss or deformity of the nail is usually to be expected. It is better to leave in place for as long as possible a nail which is going to be lost, to afford protection for the nail bed during the substitution period. Subungual exostoses are benign bony outgrowths of the dorsal surface of the distal phalanx and can be the cause of deformity and discomfort. The diagnosis is confirmed by x-ray and the treatment is removal of the growth after the nail has been removed. Recurrences are not to be expected and, if the matrix is not damaged in the process, a new and normal nail should develop. Subungual abscesses can be the result of infected hematomas, neglected paronychia, or a rupture into the subungual space of an osteomyelitic lesion of the phalanx. They are treated by simple evacuation or evacuation plus appropriate treatment of the underlying cause. Subungual glomus tumors are rare, but when they do occur there is no afHiction that is more painful. These are a combination of tissues appropriately named neuro-myo-arterial glomus and they have a predilection for the extremities. Diagnosis is based on the exquisite and constant trigger area of tenderness and the purplish discoloration. Their complete excision is followed by relief. Subungual melanomas are the most dangerous of all lesions occurring in this area and any good chiropodist always has them in mind. With the constant irritation of podiatric treatment they may spread like wildfire, and death by metastases may take place before the local primary lesion assumes an aspect of importance or urgency. Suspicion is aroused by brown pigmentation, ulceration and failure to respond to simple treatment. Biopsy is dangerous. AFFECTIONS OF THE GREAT TOE
The great toe, because of its importance in foot posture and gait, is the site of more complaints than any of the other pedal digits. Bunions and Hallux Valgus.-Aside from the affections of the nails, previously mentioned, the most common lesion of the great toe is the bunion. Unfortunately, bunions are taken too lightly by many of us and the discomfort caused by ill-advised, inadequate or poor surgery on this lesion is a complaint that is far too common. The bunion itself may be described as an inflamed bursa covering an exostosis over the medial aspect of the first metatarsal head. Such inflammation will not take place, however, unless a suitable groundwork has been laid. Any reasonably well-fitting shoe will not in itself cause enough pressure over the medial aspect of the first metatarsophalangeal joint to cause an exostosis or a bursitis, provided the great toe is reasonably in line with the shaft of the first metatarsal bone and with the second toe. The most common underlying cause, particularly in young patients, is a metatarsus primus varus deformity. This is congenital and is oharacterized .by· a medial deviation of the first metatarsal bone and
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the formation of an acute angle between this bone and the cuneiform with which it articulates. The great toe, then, when subjected to the pressure of even a properly fitting shoe, can do nothing but deviate in the lateral direction, or the patient would never be able to get a shoe on, due to the extreme width of the foot at the distal end of the metatarsals. The great toe then assumes this position of hallux valgus and the prominence on the medial side of the head of the first metatarsal then becomes subjected to pressure which, in turn, will cause the bunion formation. Narrow or pointed shoes or short stockings can produce a hallux valgus and bunion formation without serious deformity of the first metatarsal, and this frequently happens in older people. The child or adolescent, however, will invariably have all three of the factors mentioned. As time goes on, virtual partial lateral dislocation occurs at the first metatarsophalangeal joint, and enlargement and prominence will occur medially. Only a portion of the articular surface of the first metatarsal will be used in the function of this point. Traumatic arthritic changes invariably take place and a bony ridge will develop, particularly on the dorsal surface. This dorsal ridging produces a limitation of dorsiflexion of the great toe, with the result that the patient is forced to toe out in order to take a step of normal length. Such a gait, as can be readily visualized, will increase the forces that are producing the deformity and will lead to the development of calluses on the medial plantar surface of the great toe. Splaying of the forefoot and innumerable static difficulties will then arise as the result of these disturbances in this very important joint. X-rays should always be taken in order to ascertain the degree of arthritic change, and the presence or absence of smaller exostoses on the phalanges of the other toes due to pressure, and to determine the state and position of the two sesamoids that are constant beneath the first metatarsal head. Treatment.-In the conservative management of hallux valgus, one attempts to alleviate the valgoplanus that so frequently accompanies it, and to restore in so far as possible a normal gait. Every effort to correct the condition by conservative methods should be made in the case of young patients, but in older patients with arthritic changes it is doubtful whether nonoperative treatment will be completely successful over a long period of time. The problem is of course greater in women, because of the difficulty in making proper correction on shoes they are willing to wear. An attempt should be made by elevation of the medial margin of the heel to bring the hind foot into varus, and then by means of a metatarsal bar to bring the forefoot into a position of pronation. The term "pronated foot" is in one respect misleading, in that the forefoot is not pronated but actually supinated, and better weight distribution can occur only by having the proper correction of the forefoot in mind.
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The operative management of bunions does not properly come under the heading of minor surgery of the foot. It is similar in this respect to the surgical management of hernias and hemorrhoids, because these three fields are notable for not only the poor, but the many downright harmful results that may come of ill-advised surgical procedures. There are literally dozens of operations advocated for the relief of bunion pain and deformity, and I will speak only of the few that are used in this clinic with what we consider reasonable success. No operation is done routinely on all patients; the procedure is chosen to fit the patient, and not the converse. In the adolescent patient not only should the medial exostosis be removed, but an osteotomy at the metatarsocuneiform joint should be done according to the method of Lapidus. Section of the lateral capsule of the metatarsophalangeal joint, imbrication of the medial, tendon transplant and so forth mayor may not be done, according to the needs of the particular situation. It will be found in this group of patients that the restoration of the first metatarsal bone to alignment nearly parallel with the second, and the establishment of proper relaxation of the proximal phalanx on the first metatarsal will, when coupled with proper follow-up care, produce a good result. In older patients with arthritic changes we do not as a rule perform the Lapidus osteotomy but rather confine our efforts to the removal of the exostoses over all areas of the head, plus the Keller procedure. The Keller procedure is the most useful of the technics, by and large, in bunion surgery. It consists in excision of the proximal half of the proximal phalanx and, while on its completion the surgeon will note that the toe is alarmingly Hail, good stability will occur in a four to six weeks' period and a useful range of motion will develop. Proper splinting to keep the toe in alignment is necessary, and many physicians feel that a slight amount of traction on the toe during the healing period is advantageous. We do not as a rule interfere with the sesamoids unless they are grossly abnormal on x-ray or when palpated at the time of operation. AFFECTIONS OF THE SECOND TOE
It is a common observation that in many persons the second toe is longer than the great toe. As a result it is frequently injured in stubbing accidents and frequently deformed by short shoes or stockings. Fractures and Dislocations.-Fractures of the second toe are treated in the same manner as in the others, namely, by splinting, restriction of weight bearing, and skin, nail or skeletal traction if necessary. Commonly, the proximal phalanx is dislocated dorsally on the metatarsal, and reduction may be difficult to maintain. The strong pull of the extensor tendon will tend to bring the proximal phalanx into a
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position of overriding on the head of the metatarsal, and patients are not always willing to undergo the long period of immobilization necessary to permit the joint capsule to heal. The toe must be held in a position of strong flexion to overcome the tendency to dorsal displacement, and it will require from three to six weeks to heal. Mter healing has been effected, metatarsal pads should be used to keep the metatarsal head up, and in this way cause the toe to remain in a position of partial flexion. Many of these second joint dislocations are neglected and, in the case of old dislocation, repair of the capsule of the joint with maintenance of the flexion position is not likely to hold. We believe that the Keller procedure, that is, excision of the proximal half of the phalanx, is the best method of dealing with the neglected dislocation and, if the head of the metatarsal is prolapsed, as it frequently is, and gives painful symptoms on the sole, an exostectomy of the plantar surface of the metatarsal head may be added to the Keller procedure. In all cases of long-standing hallux valgus this joint should be examined for dislocation. Syndactylism.-Syndactylism between the second and third toes, extending out to the proximal interphalangeal joint, is a common incidental finding and does not require treatment. This syndactylism is usually not bony, but involves simply the skin and periosseous tissues. Hammer Toe.-A hammer toe is one in which the proximal phalanx of the toe is fixed in a position of extension and the other phalanges are fixed in a position of flexion. This results in a painful shoe pressure or friction area on the dorsal surface of the distal end of the proximal phalanx, and, since the contracture does away with the normal distribution and gripping action of the toe during weight bearing, painful areas may also develop on the plantar surface of the tip of the toe. One can conceive of this as being due to the absence of the normal resiliency of the toe, which is literally squeezed between the ground and the top of the shoe. Hammer toe occurs as a rule in the second, third and fourth toes spontaneously, but seldom occurs in the great toe unless an injury or surgical procedure has interfered with the flexion mechanism of the proximal phalanx. Our choice of operation in the usual hammer toe is excision and fusion of the proximal interphalangeal joint. This is followed by tenotomy and capsulotomy on the dorsal surface of the metatarsophalangeal joint. The fusion may be accomplished by modeling of the bone ends so that one fits the other like a dowel pin or "V" formation, or the surfaces can be cut straight across and held firmly in position during the healing period by insertion of a Kirschner wire into the end of the toe, passing down and getting a fix in the remaining portion of the proximal phalanx. Others may recommend a simple excision of the prominent portion of the distal end of the proximal phalanx, and this method requires much less time than the fusion method. It
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does away with the deformity and with the pressure or friction dorsal area, but leaves a Hail joint. A single Hail joint is not undesirable, but to treat three hammer toes by joint excision alone would certainly weaken the gripping action of the toes during the step. In the case of multiple hammer contracted toes, then, it is better to follow the excision by fusion and section of the dorsal tendon and capsule. AFFECTIONS OF THE FIFTH TOE
Congenital Dorsal Displacement.-A congenital dorsal displacement of the fifth toe is commonly seen. Mothers will call attention to it during infancy and it will give no trouble until shoes are worn. The pressure of the shoe will then cause this high-riding toe to crowd medially and override the fourth toe, and this will of course be followed by corns, calluses or actual ulceration. It will be found on examination, both clinical and x-ray, that there is an actual dorsal dislocation of this toe, and plastic procedures designed to restore it to normal position and function will probably not be successful. The fifth toe is not an important functional element to the foot and should be sacrificed if it is in a deformed position and causing symptoms. Likewise, it should be sacrificed in conditions of general contracture of all the toes, and it is our practice to do the necessary plastic or fusion procedures on the second, third and fourth toes, while at the same time amputating the fifth. A good point to remember concerning amputation of the fifth toe is that the lateral prominence of the metatarsal head may give trouble when the toe is absent. One can visualize that, without the toe, the lateral aspect of the metatarsal head will be subjected to undue pressure from the side. Therefore, a lateral ex ostectomy should be done in connection with the fifth toe amputation. The metatarsal head should not be excised. Tailor's Bunion.-The so-called bunionette or tailor's bunion is the most common of acquired lesions of the fifth toe. It consists of the gradual development of an exostosis and inflamed bursa over the lateral surface of the metatarsal head. A simple lateral exostectomy will suffice to cure the condition. Corns and Calluses.-Nearly all women, or so it seems, have either a corn or a callus on the fifth toe. This would be a good place to mention that in our work we see probably one man with a painful foot, to twenty women. This is, of course, a problem· of shoes. The SO-Galled hard corn so commonly seen on the lateral surface of the fifth toe is a callus that nature has developed to reinforce the skin and protect the underlying bone and joint structures from the pressure imposed. In the early days or weeks, however, of the imposition of this pressure, while the callus is developing, the bone is being irritated and an exostosis gradually forms on the lateral side of the interphalangeal joint surface. If the pressure is relieved by wearing properly fitting pads or a wider shoe, symptoms will subside and the exostosis
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may become less sharp or be actually absorbed. If the pressure is retained, then cure can be brought about only by removal of the exostosis. This is done by a short flap type of incision with the convexity dorsalward. The flap is reflected, the exostosis chiseled off and the incision closed. The corn or callus will then gradually soften and disappear of its own accord, because of absence of any demand for its presence. Recurrence will follow the resumption of the original pressure. The so-called interdigital or soft corns are produced by the same mechanism. They may contain a small adventitious bursa; if they do not, their softness can be attributed to the moisture and maceration of skin so commonly present in the interdigital areas. Treatment is exactly the same-protection from pressure, wider shoes or, if necessary, excision of the exostosis, which will be followed by gradual disappearance of the skin manifestations. AFFECTIONS OF THE PLANTAR SURFACE
Plantar W art.-The most common of the painful lesions of the plantar surface of the foot is the plantar wart. While' theoretically this may occur on any part of the foot, it usually occurs in or near pressure points. I have never seen one beneath the longitudinal arch nor have I seen any along the lateral margin of the weight-bearing surface. A few will occur on the heel, but most will occur in the region between the metatarsal heads and the web of the toes. They must be differentiated from melanoma with overlying callus, and from the ordinary pressure keratosis. Most plantar warts are exquisitely tender, not only on direct pressure as in walking or pushing with the finger, but on squeezing them from side to side. The fact that they occur so frequently in the area distal to the metatarsal heads, an area which is not subjected to the pressure of bony prominences underneath, suggests that they are true new growths and not solely a response to pressure or friction. Some of the tenderness will be relieved by treating the callus overlying them, and they may be helped for an indeterminate time by pads designed to minimize the pressure on them, but usually they will not be eradicated until they are destroyed by chemical, surgical or radiation treatment. Those that are actually cured by simpler means, such as the application of salves, padding of shoes and the like, are probably not true intracutaneous papillomas but rather bursae or pressure keratotic areas. Such simple measures may be helpful, however, in the differential diagnosis, and can be tried safely for many weeks. For the refractory case we favor the application of radium by those qualified to use this method. An accurate record of the dosage of either radium or x-ray applied to these lesions should be kept by the patient, because he may not get a successful result at first and, in wandering from place to place, repetitious treatment could cause a
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radiation burn with disabling ulceration. In the event of failure of radium treatment, or recurrence following initial success, excision should be considered. We do not consider excision as the primary method of treatment because we do not like to make an incision on the plantar surface of the foot. The incision should be carefully outlined so that not only skin but also a good layer of subcutaneous tissue will be available to cover the defect. In the case of a small defect, simple undermining and suture may suffice, but in the larger defect flaps may have to be transferred. In still others, particularly those with ulceration, the toe immediately above the lesion may have to be sacrificed and used without its bone as a pedicle Hap. Painful Heel.-Another common and disabling lesion of the plantar surface of the foot is the painful heel, commonly caused by an os calcis sp\lr and called by the older writers "policeman's heel." The patient will usually complain of the insidious onset of pain over the anterior surface of the pressure area of the heel. There will be no gross swelling or redness on inspection, but there will be tenderness, sometimes exquisite, over the plantar surface of the heel at the point of attachment of the plantar fascia. The symptoms will vary. Some patients will say that they are comfortable at rest, but that after siting for a long period the first dozen steps or so will be very painful and then, as activity is increased, the pain will become less and less. For others the reverse will be true. The initial steps will not be painful but pain will come on and increase as weight bearing is continued. When the x-ray is seen, a spur (usually not more than a few millimeters long) will be seen originating at the anterior. end of the os calcis, growing parallel along and into the shadow of the plantar fascia. This will correspond with the point of maximal tenderness and it will also correspond well with the fact that the tenderness is greater when the foot is placed in a position of strong dorsiflexion at the time pressure is applied. There is less tenderness when the foot is in plantar flexion and the plantar fascia thus less taut. It would seem, then, with this clinical and x-ray evidence, that the spur should certainly be the cause of the difficulty, but on close inspection it will be noted that it is not made of porous immature bone of presumably recent formation, but is dense and every bit as mature looking as the parent bone from which it arises. One then should reason that, since the presence of the spur antedates by many months or years the onset of pain, some other factor has been superimposed. What is this other factor? We believe that nature has developed over this spur an adventitious bursa, and the onset of pain coincides with the development of inflammation of the bursa. The factors producing this inflammation may be pressure or a new shoe or some minute prominence in the heel of the shoe, sometimes trauma such as a "stone bruise" or some systemic focal infection or metabolic disorder such as gout. The great majority of patients with painful heel will do well if the
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heel is protected with a horseshoe' type of sponge rubber pad, glued to the inside of the shoe so that the weight will be taken .on the periphery of the heel and not over the painful area. If gout can be established, or if reasonable foci of infection can be eradicated, then appropriate measures may be taken which, with the restriction of pressure, will produce a cure. In the follow-up of such a case it will be found that after the patient has made a complete recovery the spur is still present. When one is tempted to operate on such' a heel and remove the spur,. he should consider that spurs growing into tendons and into fascia are common throughout the body. They are seen growing into the Achilles tendon on the superior and posterior surface of the heel. They are seen growing out of the superior and inferior surfaces of the patella and from the superior surface of the olecranon, and seldom if ever are they the real cause of difficulty in or around the joints they involve. I have never removed an ordinary os calcis spur, because I have never considered them the basic difficulty. When contemplating the surgical removal of such a spur, one must remember that he is dealing with cancellous bone of great regenerative power, and a new and larger exostosis could be the result.
Ingrown Toenail.-In childhood and the teen age the most common affection of the toenails is of the medial aspect of the great toe. This affection is almost invariably due to the pressure of a malfitting shoe or short sock. The Heshy part of the medial surface is compressed so that the medial comer of the nail in its growth will perforate the epithelium and set up a low grade infection. The onset is usually followed by the appearance of a granuloma which will pile up over the edge of the nail and be fostered by the destroyed portion of the nail which acts as a foreign body or sequestrum. No direct surgical interference should be considered in the presence of active infection. It will be found that the application of warm, moist boric acid dressings and the forswearing of a shoe or sock will result in a rather rapid regression of the granuloma and the disappearance of the signs ofinHammation in the involved tissues. It is at this stage that minor surgical procedures will be effective. We hesitate to make a radical excision of the medial border of the nail and its matrix in a child, because there is no need to narrow the nail permanently, and frequently the matrix will not be completely destroyed and little spurs of nail will grow through the scar in its proximal portion. A simple excision of the comer or border of the nail or, if necessary, the removal of the entire nail without destruction of the matrix, will suffice. This can then be followed by training of the new nail as it grows out, and instruction to the parents as to the proper type of wide toe shoe and the need for adequate length in the stocking. This type of nail affiiction was seen with great frequency in the armed services and was, of course, due to the aforementioned factors, plus careless or improper foot hygiene. In the adult it is quite a different story. The nail is no longer Hat but tends to form an inverted "U," so that ingrowth and perforation of the skin covering will not only occur at the comer but may occur along the entire medial and/or lateral side. The management of the active infection is no different than in the child, but for best results the nail should later be permanently narrowed. This can be readily done under local anesthesia, obtained either by direct infiltration of the end and side of the toe or by a block of the digital nerves at the o Assistant Professor of Bone and Joint Surgery, Northwestern University Medical School; Attending Surgeon, Cook County Hospital; Attending Surgeon, Passavant Memorial Hospital, Chicago. 196
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base of the toe. A rubber band tourniquet or a twisted gauze dressing with a hemostat will give a suitable bloodless field, so that the edges of the nail bed and matrix c~n be visualized and completely removed. Following the healing phase, the patient should be cautioned to train the comers of the new nail to grow Hat, and when trimming the nail to cut only straight across. Small wisps of cotton tucked under the nail comer with a toothpick, knife blade or hairpin will keep it elevated during the training period. Dorsal Hypertrophy; Horn Formation.-Another common afHiction of the nail in adult life, particularly in the more advanced decades, is hypertrophy and piling up of the dorsum of the nail. It then has a tendency to make inroads on the Hesh of both sides, so that in looking at it from the end of the toe it forms an inverted "u" or may even be horseshoe-shaped with a circular mass of skin within it. Many such nails are the result of a true fungus involvement, but many more are simply growth abnormalities, the basis of which has not been firmly established. These patients will complain of the actual bulk of the nail pressing against the top of the shoe, and this pres~ure will in tum be referred down along the circular edges, giving pain on each side. They can be helped a good deal by shaving or filing the top of the nail Hat, so that regrowth is ,concentrated on the dorsal surface rather than on the surfaces making up the arms of the horseshoe. Also, the Hat surface will be subjected to less pressure and subsequently cause less pain. In extreme instances of actual hom formation the nails must be cut with a rongeur or bone-biting forceps, or they will have tq be removed with the hope that the new nail will have less tendency to overgrowth. In these cases chitinous debris will usually be found beneath the distal portion of the nail and this should be removed with an orange stick or cotton as part of the daily care. The application of cold cream to the cuticle and the surrounding skin will keep these structures soft and enable them to better withstand the pressure exerted on them throughout the day by the nail itself. These same lesions may occur in the nails of other toes, but seldom with the same frequency or with the same degree of irritation. There is no esesential difference, however, between the treatment of nail abnormalities of the great toe alld any other toe that might be involved. Subungual Lesions.-The subungual space is frequently the site of painful and potentially serious lesions. The commonest is the subungual hematoma which is a collection of blood due to rupture of the vessels of the nail bed. The blood then creates considerable tension within the closed space and produces a severe throbbing pain. This lesion is the result, as might be expected, of falling objects striking the nail. Relief is immediate when the hematoma is evacuated by drill hole or slit in the softer proximal portion of the nail over the
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Iunula. Simple sterile precautions will suffice as after-care, but loss or deformity of the nail is usually to be expected. It is better to leave in place for as long as possible a nail which is going to be lost, to afford protection for the nail bed during the substitution period. Subungual exostoses are benign bony outgrowths of the dorsal surface of the distal phalanx and can be the cause of deformity and discomfort. The diagnosis is confirmed by x-ray and the treatment is removal of the growth after the nail has been removed. Recurrences are not to be expected and, if the matrix is not damaged in the process, a new and normal nail should develop. Subungual abscesses can be the result of infected hematomas, neglected paronychia, or a rupture into the subungual space of an osteomyelitic lesion of the phalanx. They are treated by simple evacuation or evacuation plus appropriate treatment of the underlying cause. Subungual glomus tumors are rare, but when they do occur there is no afHiction that is more painful. These are a combination of tissues appropriately named neuro-myo-arterial glomus and they have a predilection for the extremities. Diagnosis is based on the exquisite and constant trigger area of tenderness and the purplish discoloration. Their complete excision is followed by relief. Subungual melanomas are the most dangerous of all lesions occurring in this area and any good chiropodist always has them in mind. With the constant irritation of podiatric treatment they may spread like wildfire, and death by metastases may take place before the local primary lesion assumes an aspect of importance or urgency. Suspicion is aroused by brown pigmentation, ulceration and failure to respond to simple treatment. Biopsy is dangerous. AFFECTIONS OF THE GREAT TOE
The great toe, because of its importance in foot posture and gait, is the site of more complaints than any of the other pedal digits. Bunions and Hallux Valgus.-Aside from the affections of the nails, previously mentioned, the most common lesion of the great toe is the bunion. Unfortunately, bunions are taken too lightly by many of us and the discomfort caused by ill-advised, inadequate or poor surgery on this lesion is a complaint that is far too common. The bunion itself may be described as an inflamed bursa covering an exostosis over the medial aspect of the first metatarsal head. Such inflammation will not take place, however, unless a suitable groundwork has been laid. Any reasonably well-fitting shoe will not in itself cause enough pressure over the medial aspect of the first metatarsophalangeal joint to cause an exostosis or a bursitis, provided the great toe is reasonably in line with the shaft of the first metatarsal bone and with the second toe. The most common underlying cause, particularly in young patients, is a metatarsus primus varus deformity. This is congenital and is oharacterized .by· a medial deviation of the first metatarsal bone and
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the formation of an acute angle between this bone and the cuneiform with which it articulates. The great toe, then, when subjected to the pressure of even a properly fitting shoe, can do nothing but deviate in the lateral direction, or the patient would never be able to get a shoe on, due to the extreme width of the foot at the distal end of the metatarsals. The great toe then assumes this position of hallux valgus and the prominence on the medial side of the head of the first metatarsal then becomes subjected to pressure which, in turn, will cause the bunion formation. Narrow or pointed shoes or short stockings can produce a hallux valgus and bunion formation without serious deformity of the first metatarsal, and this frequently happens in older people. The child or adolescent, however, will invariably have all three of the factors mentioned. As time goes on, virtual partial lateral dislocation occurs at the first metatarsophalangeal joint, and enlargement and prominence will occur medially. Only a portion of the articular surface of the first metatarsal will be used in the function of this point. Traumatic arthritic changes invariably take place and a bony ridge will develop, particularly on the dorsal surface. This dorsal ridging produces a limitation of dorsiflexion of the great toe, with the result that the patient is forced to toe out in order to take a step of normal length. Such a gait, as can be readily visualized, will increase the forces that are producing the deformity and will lead to the development of calluses on the medial plantar surface of the great toe. Splaying of the forefoot and innumerable static difficulties will then arise as the result of these disturbances in this very important joint. X-rays should always be taken in order to ascertain the degree of arthritic change, and the presence or absence of smaller exostoses on the phalanges of the other toes due to pressure, and to determine the state and position of the two sesamoids that are constant beneath the first metatarsal head. Treatment.-In the conservative management of hallux valgus, one attempts to alleviate the valgoplanus that so frequently accompanies it, and to restore in so far as possible a normal gait. Every effort to correct the condition by conservative methods should be made in the case of young patients, but in older patients with arthritic changes it is doubtful whether nonoperative treatment will be completely successful over a long period of time. The problem is of course greater in women, because of the difficulty in making proper correction on shoes they are willing to wear. An attempt should be made by elevation of the medial margin of the heel to bring the hind foot into varus, and then by means of a metatarsal bar to bring the forefoot into a position of pronation. The term "pronated foot" is in one respect misleading, in that the forefoot is not pronated but actually supinated, and better weight distribution can occur only by having the proper correction of the forefoot in mind.
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The operative management of bunions does not properly come under the heading of minor surgery of the foot. It is similar in this respect to the surgical management of hernias and hemorrhoids, because these three fields are notable for not only the poor, but the many downright harmful results that may come of ill-advised surgical procedures. There are literally dozens of operations advocated for the relief of bunion pain and deformity, and I will speak only of the few that are used in this clinic with what we consider reasonable success. No operation is done routinely on all patients; the procedure is chosen to fit the patient, and not the converse. In the adolescent patient not only should the medial exostosis be removed, but an osteotomy at the metatarsocuneiform joint should be done according to the method of Lapidus. Section of the lateral capsule of the metatarsophalangeal joint, imbrication of the medial, tendon transplant and so forth mayor may not be done, according to the needs of the particular situation. It will be found in this group of patients that the restoration of the first metatarsal bone to alignment nearly parallel with the second, and the establishment of proper relaxation of the proximal phalanx on the first metatarsal will, when coupled with proper follow-up care, produce a good result. In older patients with arthritic changes we do not as a rule perform the Lapidus osteotomy but rather confine our efforts to the removal of the exostoses over all areas of the head, plus the Keller procedure. The Keller procedure is the most useful of the technics, by and large, in bunion surgery. It consists in excision of the proximal half of the proximal phalanx and, while on its completion the surgeon will note that the toe is alarmingly Hail, good stability will occur in a four to six weeks' period and a useful range of motion will develop. Proper splinting to keep the toe in alignment is necessary, and many physicians feel that a slight amount of traction on the toe during the healing period is advantageous. We do not as a rule interfere with the sesamoids unless they are grossly abnormal on x-ray or when palpated at the time of operation. AFFECTIONS OF THE SECOND TOE
It is a common observation that in many persons the second toe is longer than the great toe. As a result it is frequently injured in stubbing accidents and frequently deformed by short shoes or stockings. Fractures and Dislocations.-Fractures of the second toe are treated in the same manner as in the others, namely, by splinting, restriction of weight bearing, and skin, nail or skeletal traction if necessary. Commonly, the proximal phalanx is dislocated dorsally on the metatarsal, and reduction may be difficult to maintain. The strong pull of the extensor tendon will tend to bring the proximal phalanx into a
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position of overriding on the head of the metatarsal, and patients are not always willing to undergo the long period of immobilization necessary to permit the joint capsule to heal. The toe must be held in a position of strong flexion to overcome the tendency to dorsal displacement, and it will require from three to six weeks to heal. Mter healing has been effected, metatarsal pads should be used to keep the metatarsal head up, and in this way cause the toe to remain in a position of partial flexion. Many of these second joint dislocations are neglected and, in the case of old dislocation, repair of the capsule of the joint with maintenance of the flexion position is not likely to hold. We believe that the Keller procedure, that is, excision of the proximal half of the phalanx, is the best method of dealing with the neglected dislocation and, if the head of the metatarsal is prolapsed, as it frequently is, and gives painful symptoms on the sole, an exostectomy of the plantar surface of the metatarsal head may be added to the Keller procedure. In all cases of long-standing hallux valgus this joint should be examined for dislocation. Syndactylism.-Syndactylism between the second and third toes, extending out to the proximal interphalangeal joint, is a common incidental finding and does not require treatment. This syndactylism is usually not bony, but involves simply the skin and periosseous tissues. Hammer Toe.-A hammer toe is one in which the proximal phalanx of the toe is fixed in a position of extension and the other phalanges are fixed in a position of flexion. This results in a painful shoe pressure or friction area on the dorsal surface of the distal end of the proximal phalanx, and, since the contracture does away with the normal distribution and gripping action of the toe during weight bearing, painful areas may also develop on the plantar surface of the tip of the toe. One can conceive of this as being due to the absence of the normal resiliency of the toe, which is literally squeezed between the ground and the top of the shoe. Hammer toe occurs as a rule in the second, third and fourth toes spontaneously, but seldom occurs in the great toe unless an injury or surgical procedure has interfered with the flexion mechanism of the proximal phalanx. Our choice of operation in the usual hammer toe is excision and fusion of the proximal interphalangeal joint. This is followed by tenotomy and capsulotomy on the dorsal surface of the metatarsophalangeal joint. The fusion may be accomplished by modeling of the bone ends so that one fits the other like a dowel pin or "V" formation, or the surfaces can be cut straight across and held firmly in position during the healing period by insertion of a Kirschner wire into the end of the toe, passing down and getting a fix in the remaining portion of the proximal phalanx. Others may recommend a simple excision of the prominent portion of the distal end of the proximal phalanx, and this method requires much less time than the fusion method. It
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does away with the deformity and with the pressure or friction dorsal area, but leaves a Hail joint. A single Hail joint is not undesirable, but to treat three hammer toes by joint excision alone would certainly weaken the gripping action of the toes during the step. In the case of multiple hammer contracted toes, then, it is better to follow the excision by fusion and section of the dorsal tendon and capsule. AFFECTIONS OF THE FIFTH TOE
Congenital Dorsal Displacement.-A congenital dorsal displacement of the fifth toe is commonly seen. Mothers will call attention to it during infancy and it will give no trouble until shoes are worn. The pressure of the shoe will then cause this high-riding toe to crowd medially and override the fourth toe, and this will of course be followed by corns, calluses or actual ulceration. It will be found on examination, both clinical and x-ray, that there is an actual dorsal dislocation of this toe, and plastic procedures designed to restore it to normal position and function will probably not be successful. The fifth toe is not an important functional element to the foot and should be sacrificed if it is in a deformed position and causing symptoms. Likewise, it should be sacrificed in conditions of general contracture of all the toes, and it is our practice to do the necessary plastic or fusion procedures on the second, third and fourth toes, while at the same time amputating the fifth. A good point to remember concerning amputation of the fifth toe is that the lateral prominence of the metatarsal head may give trouble when the toe is absent. One can visualize that, without the toe, the lateral aspect of the metatarsal head will be subjected to undue pressure from the side. Therefore, a lateral ex ostectomy should be done in connection with the fifth toe amputation. The metatarsal head should not be excised. Tailor's Bunion.-The so-called bunionette or tailor's bunion is the most common of acquired lesions of the fifth toe. It consists of the gradual development of an exostosis and inflamed bursa over the lateral surface of the metatarsal head. A simple lateral exostectomy will suffice to cure the condition. Corns and Calluses.-Nearly all women, or so it seems, have either a corn or a callus on the fifth toe. This would be a good place to mention that in our work we see probably one man with a painful foot, to twenty women. This is, of course, a problem· of shoes. The SO-Galled hard corn so commonly seen on the lateral surface of the fifth toe is a callus that nature has developed to reinforce the skin and protect the underlying bone and joint structures from the pressure imposed. In the early days or weeks, however, of the imposition of this pressure, while the callus is developing, the bone is being irritated and an exostosis gradually forms on the lateral side of the interphalangeal joint surface. If the pressure is relieved by wearing properly fitting pads or a wider shoe, symptoms will subside and the exostosis
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may become less sharp or be actually absorbed. If the pressure is retained, then cure can be brought about only by removal of the exostosis. This is done by a short flap type of incision with the convexity dorsalward. The flap is reflected, the exostosis chiseled off and the incision closed. The corn or callus will then gradually soften and disappear of its own accord, because of absence of any demand for its presence. Recurrence will follow the resumption of the original pressure. The so-called interdigital or soft corns are produced by the same mechanism. They may contain a small adventitious bursa; if they do not, their softness can be attributed to the moisture and maceration of skin so commonly present in the interdigital areas. Treatment is exactly the same-protection from pressure, wider shoes or, if necessary, excision of the exostosis, which will be followed by gradual disappearance of the skin manifestations. AFFECTIONS OF THE PLANTAR SURFACE
Plantar W art.-The most common of the painful lesions of the plantar surface of the foot is the plantar wart. While' theoretically this may occur on any part of the foot, it usually occurs in or near pressure points. I have never seen one beneath the longitudinal arch nor have I seen any along the lateral margin of the weight-bearing surface. A few will occur on the heel, but most will occur in the region between the metatarsal heads and the web of the toes. They must be differentiated from melanoma with overlying callus, and from the ordinary pressure keratosis. Most plantar warts are exquisitely tender, not only on direct pressure as in walking or pushing with the finger, but on squeezing them from side to side. The fact that they occur so frequently in the area distal to the metatarsal heads, an area which is not subjected to the pressure of bony prominences underneath, suggests that they are true new growths and not solely a response to pressure or friction. Some of the tenderness will be relieved by treating the callus overlying them, and they may be helped for an indeterminate time by pads designed to minimize the pressure on them, but usually they will not be eradicated until they are destroyed by chemical, surgical or radiation treatment. Those that are actually cured by simpler means, such as the application of salves, padding of shoes and the like, are probably not true intracutaneous papillomas but rather bursae or pressure keratotic areas. Such simple measures may be helpful, however, in the differential diagnosis, and can be tried safely for many weeks. For the refractory case we favor the application of radium by those qualified to use this method. An accurate record of the dosage of either radium or x-ray applied to these lesions should be kept by the patient, because he may not get a successful result at first and, in wandering from place to place, repetitious treatment could cause a
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radiation burn with disabling ulceration. In the event of failure of radium treatment, or recurrence following initial success, excision should be considered. We do not consider excision as the primary method of treatment because we do not like to make an incision on the plantar surface of the foot. The incision should be carefully outlined so that not only skin but also a good layer of subcutaneous tissue will be available to cover the defect. In the case of a small defect, simple undermining and suture may suffice, but in the larger defect flaps may have to be transferred. In still others, particularly those with ulceration, the toe immediately above the lesion may have to be sacrificed and used without its bone as a pedicle Hap. Painful Heel.-Another common and disabling lesion of the plantar surface of the foot is the painful heel, commonly caused by an os calcis sp\lr and called by the older writers "policeman's heel." The patient will usually complain of the insidious onset of pain over the anterior surface of the pressure area of the heel. There will be no gross swelling or redness on inspection, but there will be tenderness, sometimes exquisite, over the plantar surface of the heel at the point of attachment of the plantar fascia. The symptoms will vary. Some patients will say that they are comfortable at rest, but that after siting for a long period the first dozen steps or so will be very painful and then, as activity is increased, the pain will become less and less. For others the reverse will be true. The initial steps will not be painful but pain will come on and increase as weight bearing is continued. When the x-ray is seen, a spur (usually not more than a few millimeters long) will be seen originating at the anterior. end of the os calcis, growing parallel along and into the shadow of the plantar fascia. This will correspond with the point of maximal tenderness and it will also correspond well with the fact that the tenderness is greater when the foot is placed in a position of strong dorsiflexion at the time pressure is applied. There is less tenderness when the foot is in plantar flexion and the plantar fascia thus less taut. It would seem, then, with this clinical and x-ray evidence, that the spur should certainly be the cause of the difficulty, but on close inspection it will be noted that it is not made of porous immature bone of presumably recent formation, but is dense and every bit as mature looking as the parent bone from which it arises. One then should reason that, since the presence of the spur antedates by many months or years the onset of pain, some other factor has been superimposed. What is this other factor? We believe that nature has developed over this spur an adventitious bursa, and the onset of pain coincides with the development of inflammation of the bursa. The factors producing this inflammation may be pressure or a new shoe or some minute prominence in the heel of the shoe, sometimes trauma such as a "stone bruise" or some systemic focal infection or metabolic disorder such as gout. The great majority of patients with painful heel will do well if the
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heel is protected with a horseshoe' type of sponge rubber pad, glued to the inside of the shoe so that the weight will be taken .on the periphery of the heel and not over the painful area. If gout can be established, or if reasonable foci of infection can be eradicated, then appropriate measures may be taken which, with the restriction of pressure, will produce a cure. In the follow-up of such a case it will be found that after the patient has made a complete recovery the spur is still present. When one is tempted to operate on such' a heel and remove the spur,. he should consider that spurs growing into tendons and into fascia are common throughout the body. They are seen growing into the Achilles tendon on the superior and posterior surface of the heel. They are seen growing out of the superior and inferior surfaces of the patella and from the superior surface of the olecranon, and seldom if ever are they the real cause of difficulty in or around the joints they involve. I have never removed an ordinary os calcis spur, because I have never considered them the basic difficulty. When contemplating the surgical removal of such a spur, one must remember that he is dealing with cancellous bone of great regenerative power, and a new and larger exostosis could be the result.